A Towering Angell Engages Psychopharm by N. Szajnberg, MD Aug. 5, 2011
A macabre Gorey drawing initiates the NY Review of Books’ intellectual combat between Marcia Angell, former editor of the New England Journal of Medicine, and major figures in American Psychiatry: John Oldham, Richard Friedman, Andrew Nierenberg and Daniel Carlat (“The Epidemic of Mental Illness: Why?” “The Illusions of Psychiatry”; (NYR June 23; NYR July 14; IP/net Aug 3). A boy stretches tiptoed on a stool, reaching unsuccessfully for a squadron of bottles beyond his grasp. We readers are like that boy, trying to get a grasp of what’s at hand here; a battle is engaged and will be formidable; how it will proceed is uncertain. But, we also know that Angell and the New York Review of Books have ignited an important rethinking of using drugs in mental illnesses: no turning back now.
Read the IP post for the details of the arguments. In brief, Oldham, President of the APA, says Angell should have been more balanced. Carlat (whose book Angell reviewed), begins, “Her argument is correct in its essentials.” that psychiatrists over diagnose; are overly fixated on medication, have taken drug industry money. Yet, he states, drugs “on the whole, work.”
Friedman and Nierenberg give no quarter, beginning with “…Angell’s review…contains serious factual and conceptual errors…” and concluding, “she has distorted the potential adverse effects of psychotropic drugs with anecdotes and flawed data…”
Angell’s response is lengthy and detailed and crisp. She starts with “… these letters simply assume that psychoactive drugs are highly beneficial… none .. provides references … (to) substantiate that…” Then, she lists evidence, after evidence. For instance, the U.K. agency overseeing their NHS found that antidepressants provide no clinically significant change in the Ham-D depression index. In general, she restates, while there may be short-term effects for some drugs, there is no evidence for long-term efficacy. She condemns the quality of clinical research in psychiatry; as an expert in judging clinical studies, she is on solid ground.
And what about our kids? Stuart Kaplan’s Newsweek article challenges the stunning rise of bipolar disorder in children and their over medication (http://www.thedailybeast.com/newsweek/2011/06/19/mommy-am-i-really-bipolar.html). Biederman’s life’s work is discredited in part because of his dealings with pharmaceutical companies: when he claims that 1-4% of all U.S. children are bipolar; his credibility suffers further. Kaplan argues that bipolar is a fad diagnosis; that many of the symptoms described in recent popular books, such as Brandon and the Bipolar Bear (imagine Where the Wilds Thing Are revised to sell drugs), portray either the norms of childhood, or (Kaplan argues) more parsimonious diagnoses.
Adolescents often keep us honest or at least not hypocritical: they point out that we tell them (consciously) not to use street drugs, then say that we have just the right drug for you in our cabinet. And colleagues will try to respond to the teen, “You are trying to medicate yourself for your (fill in the diagnosis); I can do it better for you.” But, can we? And why, in many cases, can’t we use the more sophisticated, highly individualized treatment of interacting with the teen (or adult) examining feelings, thoughts, wishes, fears, dreams: that engagement we call psychoanalysis; a treatment that our brain-imaging colleagues may some day show results in pharmacological or neuro-structural changes (If we do our treatment well.).
The New York Review of Books, Angell, Newsweek and Kaplan have provided an important public service, a breach in the wall of big pharma. Psychoanalysts can step into that breach to promote what is in society’s better interest.
Here analysts meet a great challenge. Can we begin to initiate the careful study of adult analytic outcome as Leutzinger-Bohleber and colleagues have done in Germany, or Fonagy and Target’s courageous reexamination of the records in the Anna Freud clinic to find out what works (and doesn’t work as effectively) with children? This kind of research takes a team; takes a discipline willing to support its teams; and takes scientific courage.
Psychoanalysts can show that we are willing to examine our practices and strut our stuff.